Obituary: RIP to the EHR

I just received another email from another EHR Vendor pandering to physicians to implement their technology so that the physician so they can access some usability incentive to use technology that they should already be using. Here is the offending language:

State Medicaid providers across the country have an unprecedented opportunity to collect over $21,000 in EHR incentives in the last few weeks of 2011. If you’re already using Xxxxxxxx Xxxxxx, there are a few easy steps you can take to earn your incentive.

This is just so wrong on so many levels to me. First, I find it completely incongruous that we have to incent physicians to use a simple tool that is designed to make their life easier, their practice more efficient, and their care more effective. I can’t recall, but I didn’t see the need to incent the stethoscope, antibiotics, or any other health innovations.

Second, the offer itself is just dripping with the grease and slime of “taking” something “while the getting is good”. Does anyone care that this “stimulus” money is subject to the grossest abuses? That it will be misapplied? That most of it is being doled out to people who have already implemented these technologies and now are getting a little gloss on top? Does anyone care that our country is broke and this is just another program that is unsustainable, unnecessary, and incapable of producing its intended results. Is there any evidence that this is having an impact?

And third, perhaps most fundamentally, we are incenting the wrong thing. The EHR is not the end all be all technology to implement into practices across the country. One of the most thoughtful newer EHR companies puts this entire notion into perspective. ClearPractice, a subsidiary of Essence Health Group, list out 22 capabilities that are required to achieve the triple aim of lower costs, increased quality, and improved outcomes. The EHR is only ONE aspect of the requirements to achieve this. Double take on that – only One of Twenty Two core capabilities – less than 5%. That is the point.

I personally believe that the EHR, while a useful tool, is a commodity being overtaken by an entirely new range of capabilities, integration, and technologies that are allowing innovators to help make health a more seamless and less disruptive part of their life. I am thinking about data aggregation and visualization like Mint.com (showing all your spend, claims, and health planning) real life timeline and interactions (complete with pictures, images, labs, results, etc) in a Facebook Timeline motiff, and making it fun and engaging by making the ultimate social experience (your health and that of those you love) much more social and interactive regarding a much more comprehensive view of what “health” actually is.

So EHR, thank you for your venerable service in helping to establishing a foundation of health. Now, rest in peace.

Scott Shreeve is a physician and entrepreneur based in Laguna Beach, California. After a long career in medicine, Scott founded the open source electronic medical record company MedSphere. He blogs regularly at CrossOver Health, where this post first appeared.

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20 replies »

  1. I agree, the astute practice manager and owner don’t have to be subsidized or even duped into converting their systems to be more efficient and organized.

    EHR should be just one of a list of items needed for the 21st Century medical practice to survive and thrive. There are new technologies for automated patient payment systems and software programs that should also be considered. To be specific, fully integrated eligibility AND payment solutions that interface with PMS/EMR systems. A medical office can verify & estimate patient insurance coverage in real time, and calculate patient balance owed, and collect payment from patient at point of care or set up pre authorized recurring monthly payments.

    Solutions for eliminating patient bad debt, and reducing billing costs are just as important to the modern practice as is the implementation of a quality EHR/EMR solution!

  2. Having been involved in Healthcare for the last 30 years, I’m in agreement with Tim. Does anyone remember the days of the pegboard system? It was the same scenario until penalties where introduced into the process. Then the practices adopted electronic claims filing. Now, if you told someone to type out or hand write a claim, they would look at you as if you had a third eye.

    I think the issue is that if it doesn’t affect the pocketbook, then everyone takes a it’s fine the way it is, why go through the hassle of change attitude?

    The local fast food outlet is more automated and efficient than a medical practice. Part of what drives that is that they need to make a profit on a $2.00 taco. As healthcare margins contine to get squeezed, practices are going to ned to stramline their processes and reduce the touch cost of interacting with their pationt while providing high quality care. That efficiency is going come from technology and it will contribute to the long term health of the practice.

  3. I don’t think docs would have any problem with the idea that they are being using as cannon-fodder by the powers higher up.

  4. It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest,

    The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

    Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall.

  5. I would never work for you.

    I have never had a patient ask me to use an EHR (guess I should say ask me IF I use an EHR since I have always used an EHR) They simply are not demanding it. You might say because no one has ever explained it to them but I would answer you can’t, because there is no benefit – yet.

    It is sad that you (the collective you) have to drag us kicking and screaming to the EHR party. This could be avoided if someone would show some leadership and legislate what is truly needed – interoperability and standards (and legal protection when standards are followed) for sharing information. I know this is coming, but it is not yet here. Your patients, in your giant mega clinic system, may benefit from EHR now, but the real promise will not be realized until the interoperability standards are in place and functioning.

    Many communities already have systems for sharing of labs and imaging, but this has nothing to do with EHRs. I have lab integration in my EHR, sure it’s nice, but I haven’t seen any end user benefit over the faxes we used to receive.

    Any one who says that computerized records are currently at anywhere near the full potential of what is already possible with current technology are smokin’ something. They are all, I mean all, poorly written, cumbersome, extraordinarily expensive pieces of $%$#$%.

  6. It never ceases to amaze how out of touch the physicians are with what is going on around their own profession.

    The biggest gain from an EHR has nothing to with making a physician’s life easier, nor with “improving care” — if care is defined by the physicians. But if their customers are allowed to have a small part in the definition of “care”, then the horrible experiences that many patients have with fragmented medical information and sloppy communication among providers will be part of that “care”. If you”ve ever had an elderly parent with a serious illness and felt like you needed to personally shepherd them through the system, or crucial information would never make it from here to there, you know what I mean. (By the way, most physicians and their families are still treated with special attention in their care, whether they know it or not — so, no, you don’t know what this is like.)

    Your customers are trying to tell you that the EXPERIENCE you are delivering with your paper-based system is not acceptable. It’s tragic that most professions who go through this type of paradigm-shift (the cliche happens to apply) fight till the end and lose. The dinosaurs do not become mammals. They just die, and the mammals move in.

    Full disclosure: I’m one of those group practice CEO’s. The EHR companies obviously want to sell me their product…but physicians are notorious for refusing to take part in a project, then complaining they were left out of it. Physicians as a rule do not understand the systems they are a part of, and work hard at staying that way.

    Most of the good and bad of EHR’s is in the local implementation of the software. I can take you today to many physicians who are entirely on an EHR and they see more patients in less time (and their notes are short and concise) than before. They’ve taken the time and work to make it happen. Those who talk the physicians moaning on this board are soon to be a minority.

    There is simply nothing unique about medicine that makes it exempt from the economic and societal pressures that computerize everything. Here is what is going to happen: every physician in America will use an EHR. There will some doctor pain associated with this. In the end, care will be better, as defined both by the physicians and their patients, and everyone will think about the old way like we now think about horses and buggies.

    It is simply not possible that this won’t happen.

  7. I agree, EHR may not be the way to go. However, using consumer based technology can make it easier for patients to manage their health. I love the idea of a mint.com for health. Instead of an EHR we could create simple and effective tools for everyday people to track medications, keep appointments and do a million other things that I haven’t thought of. I think the problem is not focusing on the consumer as mint.com does. Why make the hospitals spend a ton of money on EHR when you can empower the patients to use technology to manage their own health.

  8. Don’t kid yourself. EHR is designed for the federal government and only for the feds. They want it so bad they will lure us with promises of great riches if we just play ball.

    What big teeth you have, Grandma.

  9. Well, Apple has to convince each consumer — and they have to KEEP convincing you or you’ll switch to some other phone. So every day they work to make their customers happy.

    GE just has to please the CEO and CTO of the hospital — once. Then with all the sunk investment they can safely ignore them. So they design nice presentations that convince those key people — their customers.

    The physicians and nurses and other staff are not GE’s customer. The CEO is. So the staff are ignored.

  10. This is the crux of the matter. The EHR software sucks for the most part. I always wonder who designs the stuff and who are they designing it for. Also, would it be too much to ask that it comes with an app you can easily put on your phone and use?


  11. “a simple tool that is designed to make their life easier, their practice more efficient, and their care more effective.”

    That’s not why EHRs are designed.

  12. In my experience as a pediatrician in a university setting, the EHR system that has been implemented has been designed not to make doctors lives easier or their practice more efficient or their care more effective. It has been designed to make money for GE, the developer of Centricity. The system looks and acts like it was designed in 1990, and makes many of the simplest tasks painful and time-consuming.

    When compared with the elegant software we have all become accustomed to using in our personal computing, like Yahoo Mail, Google Maps, the iPhone, etc, it looks even worse — and raised the question as to WHY the software the hospital paid so much for is SO much worse than the software in our personal lives — much of which is provided to me for free.

    Right now I use the EHR because I am required to in order to practice at my hospital. I hope that one day I’ll use an EHR because it actually (1) saves me time and/or money (2) and/or (2) improves patient outcomes.

  13. Hard to argue with much of that.

    “I’m not sure that $35 billion over several years is such a waste of taxpayers money.”

    Question: Every time I see the HITECH reimbursement money cited, it grows. First it was $20 billion, then $27 billion, now you say $35 billion.

    Just the MU reimbursement piece, not all the other ARRA/HITECH stuff.

    BTW, 2011 Iraq and Afghanistan alone cost us $138 billion. Overtly, not counting all the residual costs in years to come. One year. So comparatively, ~6.5% spent on MU — and no one gets their legs blown off.

    Nonetheless, we are indeed seeing a legacy install free money grab to a disturbing extent. And, then, you got guys like Jonathan Bush — the Donald Trump of HIT — crassly dissing HITECH at every turn while concomitantly slurping up every dollar that flows through to AthenaHealth.

    “In every other country that got to 100% of primary care use of EMRs, doctors had the tech paid for by the government and weren’t really given a choice.”

    Well, see my blog post “Use Case,” wherein I cite at length JD Kleinke’s great post on the topic: “Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System”

  14. Scott is correct in his veiled fear that we’re risking the implemention of a set of technologies that lock in the past. Indeed Kaiser is going to get a big payment for already putting in Epic (although no where enough to cover the cost). But the sad fact of the matter is that doctors do what they get paid for. In every other country that got to 100% of primary care use of EMRs, doctors had the tech paid for by the government and weren’t really given a choice.

    Was this the very best way to spend $35billion? In theory no, but in practice given how else we waste money in health care (stents? spinal fusions) I’m not sure that $35 billion over several years is such a waste of taxpayers money. And as Scott says, the EMR is part of the solution.

    So i share his fears, and I too believe that the EMR will soon be superseded. After all I’m on record as saying it doesnt exist.

    But in a country that was spending $35 billion every couple of months in Iraq and spent $200 billion bailing our General Motors (even if we got it back), and in which we DREAM of only wasting $35 billion a year on health care, using that relatively modest amount over several years to push physicians in the right direction isnt such a bad thing.

  15. Dr, Sheeve: While I’m not a MD, however I do have an Uncle who’s retired and like him so many provides are concerned about the cost to implement an EHR system and other technology. It seems like each provider I talk to (Carolina’s) say that their thinking about retirement before they will implement EHR. Which puzzles me and quite often causes me to ask the provider a series of questions. If their retireing because their tired of SGR and other programs cutting their profit margin then I can understand. If their go into retirrment for fear of technology then I explain to them why & how they can implement HIT into their practice potentialy improving productivity, QOC, & improved profit margins, by this time their eye’s are usally bulging and ready to hear what I have to say. I strongly belive that provided safety measures are put into place like HIPPA/HITECH, and costs of implementation start to go down/decrease the industry will start to feel more comfortable with technology and true QOC can start to be seen.

  16. ” First, I find it completely incongruous that we have to incent physicians to use a simple tool that is designed to make their life easier, their practice more efficient, and their care more effective.”



  17. I have to agree with much of what you say. With some questions.

    “That most of it is being doled out to people who have already implemented these technologies and now are getting a little gloss on top?”

    Well, that’s the Senator Coburn argument. He’s on record as wanting to rescind the MU incentive funds.

    But, you cite ClearPractice (MU CHPL Number 12152010-2155-1), and on their site I see:

    “We’re committed to breaking down any barriers between your practice and all the benefits of Meaningful Use – including stimulus payments that could be worth up to $44,000. That’s money you can invest right back into your practice. So we’ve made ClearPractice easy to purchase, easy to implement and easy to use.

    The integrated ClearPractice solution gives you everything you need to qualify for up to $44,000 in stimulus funding – including scheduling, charting, prescribing, lab review/ordering, messaging and more.”

    Explain to me how they differ from the others in touting the MU money. How are they not just one more HIT vendor?

    “I can’t recall, but I didn’t see the need to incent the stethoscope, antibiotics, or any other health innovations.”

    C’mon, doc. EVERY invention/innovation is the result of some “incentive.” Some are altruistic, some are policy-driven, some are profit-driven (and the three are not mutually exclusive — none of which is to imply that this or that incentive is rational or perverse).

    I will likely cite you on my REC blog.